Universal Primary Care -- Health Care. Reform. Shovel Ready Now.

1. Universal Primary Care --Health Care. Reform.Shovel Ready Now. Michael D. Fine, M.D. Society of Primary Care Policy Fellows March 26, 2009

2. We Have Also Met The Solution -- Universal Primary Care • Every person has access to a primary care practice. • Each primary care practice responsible for the primary health care of everyone who lives nearby.

3. Primary Care is the only medical service that has ever been shown to improve the health of the population.Primary Care keeps people out of the emergency room, out of the hospital, and away from medical services that are dangerous and unnecessary.Primary care practices are places that know people and are known by them. Primary care practices are places people can ask questions. Primary care practices listen.

4. Universal Primary Care : incredibly affordable • Per person per year cost of health care in the US >$8000 • Per person per year cost of health plan administration -- $500-1500 or more • Per person per year cost of primary care--$200-300

5. Universal Primary Care : Workforce in Place • 240,416 primary care physicians • 98,328 family physicians/general practitioners • 92,917 general internists • 49,171 general pediatricians • (83% practicing in in groups of less then 3) • About 1/3 of the total US physician workforce • 22,000 Physician Assistants (2004) • 92,000 Nurse Practitioners (2004)

6. Universal Primary Care : Working Hard for America Now. • Primary care is already America’s health care system. • Each primary care practice organizes the only health care system we have around the patients they care for. • Primary care practices provide 50-60 percent of all daily patient contacts in the US. • About 75 percent of American adults, and about 65 percent of the parents of American children, can name a primary care physician or practice as their usual source of health care.

7. Primary Care is Effective: More primary care physicians per capita is associated with higher quality medical care

8. 10000 PYLL Low PC Countries* 5000 High PC Countries* 0 1970 1980 1990 2000 Year Primary Care: The Stealth Health Care System: Primary Care Strength and Premature Mortality in 18 OECD Countries *Predicted PYLL (both genders) estimated by fixed effects, using pooled cross-sectional time series design. Analysis controlled for GDP, percent elderly, doctors/capita, average income (ppp), alcohol and tobacco use. R2(within)=0.77. Starfield 10/04 04-247 Starfield 09/04 IC 2953 Source: Macinko et al, Health Serv Res 2003; 38:831-65.

9. Primary Care: The Stealth Health Care System Greater numbers of primary care physicians per capita is associated with lower cost care

10. Greater numbers of primary care physicians per capita is associated with lower cost care

11. Primary Care is Effective and Affordable: Health Care Expenditures and Mortality 5 Year Followup:United States, 1987-92 • Adults (age 25 and older) with a primary care physician rather than a specialist as their personal physician: • had 33% lower cost of care • were 19% less likely to die prematurely (after controlling for age, gender, income, insurance, smoking, perceived health (SF-36) and 11 major health conditions) Source: Franks & Fiscella, J Fam Pract 1998; 47:105-9.

12. Primary Care is Effective and Affordable: Community Health Centers • CHCs - a multidisciplinary primary care team to care for the underserved: • Provide care at 41 % less cost • With the best measured quality of any primary care in the US Source: Access Granted NACHC/Robert Graham Center 2007

13. Community Health Centers and Primary Care Saves Money, Regardless of Income

14. Why The Savings? • Emergency room utilization is 24 percent lower in areas with more family physicians • Hospital costs for Medicare beneficiaries are 26 percent lower in areas with more family physicians

15. How much can primary care save? • We spend $700 billion a year on Medicaid and Medicare • save 30% = $210 billion, Medicare + Medicaid alone • Primary care for 47 million uninsured x $400 = $19 billion • Primary Care for all Americans 300 million x $400 = $120 billion • Save 8 % on all health care expense = $200 billion • save 41% on all health care expense = $1 trillion • $1 trillion buys lots of housing, education, improved environments and public safety

16. So What If We Provided Primary Care To All Americans? • Say we changed the primary care infrastructure, so anyone who now has a usual source of care has access to a practice that was organized on a community health center model – but we didn’t bring that model to anyone new ? • Anticipated Savings, $137-519 Billion

17. So What If We Provided Primary Care To All Americans? • Say we changed the primary care infrastructure, so who now has a usual source of care has access to a practice that was organized on a community health center model – and we gave everyone without a usual source of care only primary care ? • Anticipated Savings, $113-495 Billion

18. So What If We Provided Primary Care To All Americans? • Say we changed the primary care infrastructure, so who now has a usual source of care has access to a practice that was organized on a community health center model – and we gave everyone without a usual source of care health insurance and primary care ? • Anticipated Savings, $59-371 Billion

19. So What If We Provided Primary Care To All Americans? • Now say we just gave health insurance to everyone without a usual source of care ? • Anticipated newspending, $119 Billion !!! • (Know how to spell “Massachusetts”?)

20. So What If We Provided Primary Care To All Americans? • Infant mortality drops 13 percent, which saves 544, 522 lives • Life expectancy increases 1 year • Heart disease mortality drops 16 percent, which saves 102,000 lives • Stroke Mortality drops 5 percent, which saves 6000 lives • (and we’d have more people around to buy houses and bring back the housing market)

21. Universal Primary Care • Imagine…. • Having one practice care for 90 percent of a community’s health care needs… • That 90 percent of a community uses… • Imagine having a country blanketed with these practices. • Imagine….. A health care system!!!! – built from the ground up!!!! In these United States!!!!

22. Universal Primary Care - Yes We Can! • Backbone • Existing private practices • Care for about 180-200 million American now • 83 percent in practices of 1 or 2 physicians • Community Health Center Model – the gold standard • Cares for 16 million Americans • Best measured primary care in the US • Have focused on the uninsured, but have developed a cost effective model that can be widely deployed

23. Universal Primary Care - Yes We Can! • 15,000-30,000 Health Stations • Physicians • PAs and Nurse practitioners • Community Health Workers • Nurse Midwives • Social Workers • Psychologists • Nutritionists • Nurse Care Managers • Home Health Workers • Physical Therapists • Epidemiologists and Medical Anthropologists

24. Universal Primary Care - Yes We Can! • 15,000-30,000 Multidisciplinary Health Stations • One for every 10,000-20,000 people • Dual backbone • 12,000-24,000 private, hospital, or community owned Health Stations • 3000-6000 Federally Qualified and funded Community Health Center Health Stations

25. Universal Primary Care - Yes We Can! • 15,000-30,000 Health Stations • Open or advanced access • 8am to 8PM • Nights and weekends • 24 hour telephone coverage • Responsible for the health of a population • EMR enabled choice, chronic disease management, and learning

26. Universal Primary Care - Yes We Can! • State Primary Care Trusts • Boots on the ground, building the infrastructure • Business development center/extension agent model • Loan repayment programs • Data Center • Advocacy • ? Fund-holding • Graduate Medical Education • Primary Care Organization, to assess need, and then midwife the build-out of CHCs

27. Universal Primary Care - Yes We Can! • Infrastructure support • Assistant Secretary for Primary Care (HHS) • State Primary Care Trusts • State Health Department Quality and transparency oversight of Health Stations • Community Health Boards

28. Universal Primary Care - Yes We Can! • Expected Outcomes • 10-30 percent savings • Improved population health • Everyone in

29. Universal Primary Care – Summary and Conclusions • Primary care is a keystone of health care reform • Primary Care is affordable and effective • Workforce and infrastructure is in place now. • Minimal system re-organization is required to bring everyone in, improve outcomes, and reduce cost • Health insurance reform without universal primary care is likely to be very expensive.

30. Thanks to • Steven Petterson PhD • Robert Phillips MD • Andrew Bazemore MD • Bridget Teevan • Kirsten Thomsen PA-C • The Society of Primary Care Policy Fellows

31. Universal Primary Care Health Care. Reform.Shovel Ready Now. Michael D. Fine, M.D. Society of Primary Care Policy Fellows March 26, 2009

32. Universal Primary Care - Yes We Can! • Communities are central • own practice buildings and contract with practices 5 years at a time • Incentives: • subsidized space • Capitated payments to advance public interest programs • Immunization/open access/ public health programs • Private practice continues to exist on a parallel track , but without public funding • Robust HIT unifies the population base

33. Universal Primary Care - Yes We Can! • Federal role • building loans to communities (Use the water treatment model) • Fund Community Health Centers • Workforce policy • Fund graduate medical education • Fund research • Clinical effectiveness • Health services

34. Universal Primary Care- Yes We Can! • Financing (initial) • Use existing health insurance, and require participation • SUBSIDIZE THE UNINSURED • Carve out of health insurance, and require tax advantaged participation • SUBSIDIZE THE UNINSURED • Scoop out of existing health insurance, Medicare and Medicaid. • SUBSIDIZE THE UNINSURED • Financing (mature) • Health boards have taxing authority • Local , state, or federal taxes